Hospital Patient Safety Initiatives: Infection Control Bernard C. McDonnell, DO

Urinary Catheter Tracer Use of urinary catheters in a manner to minimize infection Use of urinary catheters in a manner to minimize infection Hospital maintains guidelines for appropriate use of urinary catheters Hospital maintains guidelines for appropriate use of urinary catheters Hand hygiene Hand hygiene Before and after insertion Before and after insertion Placement of catheter using aseptic technique Placement of catheter using aseptic technique Catheter properly secured after insertion Catheter properly secured after insertion

Urinary Catheter Tracer Catheter insertion and indication are documented Catheter insertion and indication are documented Hand hygiene before and after manipulation of catheter Hand hygiene before and after manipulation of catheter Avoid irrigation Avoid irrigation Collection bag emptied using aseptic technique Collection bag emptied using aseptic technique Aseptic collection of urine samples Aseptic collection of urine samples Small amounts through needleless port Small amounts through needleless port

Urinary Catheter Tracer Keep urine collection bag below level of bladder at all times Keep urine collection bag below level of bladder at all times Catheter tubing unobstructed with no kinking Catheter tubing unobstructed with no kinking Need for catheter reviewed daily Need for catheter reviewed daily Prompt removal when deemed unnecessary Prompt removal when deemed unnecessary No “convenience” No “convenience”

Central Venous Catheter Tracer Central venous catheters are inserted, assessed and maintained in a manner to minimize infection Central venous catheters are inserted, assessed and maintained in a manner to minimize infection Hand Hygiene performed before and after insertion Hand Hygiene performed before and after insertion Maximal barrier precautions used for insertion Maximal barrier precautions used for insertion Surgical protection including full patient body drape Surgical protection including full patient body drape Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to insertion Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to insertion Can use tincture of iodine, iodophor or 70% alcohol alternatively Can use tincture of iodine, iodophor or 70% alcohol alternatively

Central Venous Catheter Tracer Dressing to cover catheter insertion site Dressing to cover catheter insertion site Sterile gauze Sterile gauze Transparent, semi-permeable dressing Transparent, semi-permeable dressing Well healed and tunneled catheters may not need to be covered Well healed and tunneled catheters may not need to be covered Central line insertion and indication documented Central line insertion and indication documented Hand hygiene performed before and after manipulating catheter Hand hygiene performed before and after manipulating catheter Gloves Gloves Soiled dressings are changed promptly Soiled dressings are changed promptly All dressings changed using aseptic technique All dressings changed using aseptic technique Gloves Gloves

Central Venous Catheter Tracer Access port is scrubbed with an appropriate antiseptic prior to accessing Access port is scrubbed with an appropriate antiseptic prior to accessing Chlorhexidine Chlorhexidine Povidone iodine Povidone iodine An iodophor An iodophor 70% alcohol 70% alcohol Catheter accessed with sterile devices Catheter accessed with sterile devices Need to central venous catheters reviewed daily with prompt removal when not necessary Need to central venous catheters reviewed daily with prompt removal when not necessary

Ventilator/Respiratory Therapy Tracer Respiratory procedures are performed in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease Respiratory procedures are performed in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease Hand hygiene Hand hygiene Gloves Gloves Sterile water for nebulization Sterile water for nebulization Single dose vials for aerosolized medications Single dose vials for aerosolized medications Using manufacturer’s instructions for handling, storing and dispensing of medications Using manufacturer’s instructions for handling, storing and dispensing of medications

Ventilator/Respiratory Therapy Tracer If multi-dose vials for aerosolized medications are used for more than one patient— If multi-dose vials for aerosolized medications are used for more than one patient— Restricted to a centralized medication location Restricted to a centralized medication location They do not enter the immediate patient treatment area They do not enter the immediate patient treatment area

Ventilator/Respiratory Therapy Tracer Ventilators are used in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease Ventilators are used in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease Ventilator circuit is changed if visibly soiled or mechanically malfunctioning Ventilator circuit is changed if visibly soiled or mechanically malfunctioning Sterile water is used to fill bubbling humidifiers Sterile water is used to fill bubbling humidifiers Condensate in tubing is periodically drained and discarded Condensate in tubing is periodically drained and discarded Condensate should not drain toward the patient Condensate should not drain toward the patient

Ventilator/Respiratory Therapy Tracer Use of sterile single-use suction catheter Use of sterile single-use suction catheter Multi-use closed system catheter Multi-use closed system catheter Only sterile fluid is used to remove secretions Only sterile fluid is used to remove secretions Sedation is lightened daily in eligible patients Sedation is lightened daily in eligible patients Spontaneous breathing trials are performed daily in eligible patients Spontaneous breathing trials are performed daily in eligible patients “Weaning” “Weaning”

Spinal Injection Procedures Spinal injection procedures are performed in a manner to minimize infection and the spread of communicable disease Spinal injection procedures are performed in a manner to minimize infection and the spread of communicable disease Hand hygiene Hand hygiene Spinal injection Spinal injection Aseptic technique Aseptic technique Surgical masks are used when placing a catheter or injecting materials into the epidural or subdural space Surgical masks are used when placing a catheter or injecting materials into the epidural or subdural space

Point of Care Devices Blood Glucose Meter Blood Glucose Meter INR Monitor INR Monitor

Point of Care Devices Hand hygiene Hand hygiene Gloves Gloves Used for “finger-stick” procedures Used for “finger-stick” procedures Removed after the procedure Removed after the procedure Followed by hand hygiene Followed by hand hygiene Finger stick devices are used for 1 patient Finger stick devices are used for 1 patient Lancet Lancet Lancet holding device Lancet holding device

Point of Care Devices Point of Care device is cleaned and disinfected after every use according to manufacturer’s instructions Point of Care device is cleaned and disinfected after every use according to manufacturer’s instructions Single use only if no manufacturer’s instructions for cleaning and disinfection Single use only if no manufacturer’s instructions for cleaning and disinfection

Isolation/Contact Precautions Patients requiring contact isolation are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease Patients requiring contact isolation are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease

Isolation/Contact Precautions Gloves are available and located near point of use Gloves are available and located near point of use Signs indicating that the patient is in contact isolation Signs indicating that the patient is in contact isolation Patients in contact isolation are in single rooms Patients in contact isolation are in single rooms Can be cohorted based on clinical risk assessment Can be cohorted based on clinical risk assessment

Isolation/Contact Precautions Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus during an outbreak. In all other situations, ABHR is preferred.

Isolation/Contact Precautions Gloves and gowns Gloves and gowns Before entering patient care environment Before entering patient care environment Removed and discarded; hand hygiene is performed before leaving the patient care environment Removed and discarded; hand hygiene is performed before leaving the patient care environment

Isolation/Contact Precautions Dedicated or disposable noncritical patient- care equipment (e.g., blood pressure cuffs) is used or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions. Dedicated or disposable noncritical patient- care equipment (e.g., blood pressure cuffs) is used or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions.

Isolation/Contact Precautions Traffic control Traffic control Into patient’s room Into patient’s room Patient moving out of the room to other parts of the hospital Patient moving out of the room to other parts of the hospital Contact precautions outside the patient’s room Contact precautions outside the patient’s room Cleaning of objects and patient care areas that are touched in patient’s isolation room Cleaning of objects and patient care areas that are touched in patient’s isolation room When visibly soiled When visibly soiled At least once a day At least once a day Terminal cleaning Terminal cleaning All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean textiles All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean textiles Cleaners and disinfectants are labeled and used in accordance with hospital policy and procedure and manufacturer’s instructions Cleaners and disinfectants are labeled and used in accordance with hospital policy and procedure and manufacturer’s instructions

Isolation: Droplet Precautions Patients requiring Droplet Precautions are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

Isolation: Droplet Precautions Masks On entering Discarded when leaving Signs Patient on droplet precautions are housed in a single room or cohorted based on clinical risk assessment Hand hygiene Limited patient movement for droplet isolation patients Medically necessary procedures Patient wears surgical mask when transported Communication of patient’s status

Isolation: Droplet Precautions Cleaning Cleaning Once a day per policy and manufacturer’s instruction while patient is admitted Once a day per policy and manufacturer’s instruction while patient is admitted Terminal cleaning after discharge including wiping and disinfection of all hard surfaces Terminal cleaning after discharge including wiping and disinfection of all hard surfaces Changing all textiles in the isolation room Changing all textiles in the isolation room All cleaners are used in accordance with hospital policy and procedure and manufacturer’s instructions All cleaners are used in accordance with hospital policy and procedure and manufacturer’s instructions

Isolation: Airborne precautions Patients requiring Airborne Precautions are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

Isolation: Airborne precautions Use of N-95 or higher particulate respirators Use of N-95 or higher particulate respirators Available and near point of use Available and near point of use Signs indicating patient is on airborne precautions Signs indicating patient is on airborne precautions Clear and visible Clear and visible Patients on airborne isolation are housed in airborne isolation rooms Patients on airborne isolation are housed in airborne isolation rooms Hand hygiene before entering Hand hygiene before entering And leaving And leaving N-95 or higher particulate respirator to be worn when entering patient room for confirmed or suspected TB N-95 or higher particulate respirator to be worn when entering patient room for confirmed or suspected TB

Isolation: Airborne precautions Facility limits movement of patients on airborne isolation to medically necessary purposes Facility limits movement of patients on airborne isolation to medically necessary purposes Patient wears surgical mask per hospital policy Patient wears surgical mask per hospital policy Hospital has means to communicate patient’s status Hospital has means to communicate patient’s status

Surgical procedure tracer Surgical procedures are performed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

Surgical procedure tracer Surgical scrub before donning of sterile gloves for a surgical procedure in the OR Surgical scrub before donning of sterile gloves for a surgical procedure in the OR Use of either Use of either Antimicrobial surgical scrub Antimicrobial surgical scrub FDA-approved alcohol-based antiseptic surgical hand rub FDA-approved alcohol-based antiseptic surgical hand rub Visibly soiled hands should be washed with soap and water prior to the above procedures Visibly soiled hands should be washed with soap and water prior to the above procedures After surgical scrub hands and arms are dried with a sterile towel and sterile surgical gown and gloves are donned in the OR After surgical scrub hands and arms are dried with a sterile towel and sterile surgical gown and gloves are donned in the OR

Surgical procedure tracer Surgical attire Surgical attire Scrubs Scrubs Surgical caps/hoods covering all head and facial hair Surgical caps/hoods covering all head and facial hair Worn by all personnel in semi restricted and restricted areas Worn by all personnel in semi restricted and restricted areas Restricted areas include Restricted areas include OR OR Procedure rooms Procedure rooms Clean core Clean core Semi restricted areas include Semi restricted areas include Peripheral support areas of the surgical suite Peripheral support areas of the surgical suite

Surgical procedure tracer Masks Masks Properly tied and fully covering mouth and nose are worn by all personnel in restricted areas where open sterile supplies or scrubbed persons are located Properly tied and fully covering mouth and nose are worn by all personnel in restricted areas where open sterile supplies or scrubbed persons are located Sterile drapes are used to establish the sterile field Sterile drapes are used to establish the sterile field Sterile field Sterile field Items in sterile field are sterile Items in sterile field are sterile Items introduced to the sterile field are opened, dispensed and transferred in a manner to maintain sterility Items introduced to the sterile field are opened, dispensed and transferred in a manner to maintain sterility Established in a location where it will be used and as close as possible to the time of use Established in a location where it will be used and as close as possible to the time of use Movement around the sterile field is done in a manner to maintain sterility Movement around the sterile field is done in a manner to maintain sterility

Surgical procedure tracer Traffic in and out of the OR is kept to a minimum and is limited to essential staff Traffic Control Policies and Procedures Surgical masks are removed when leaving the sterile areas and are not reused when returning

Surgical procedure tracer Cleaners and disinfectants Cleaners and disinfectants Used according to hospital policy and procedure and manufacturer’s instructions Used according to hospital policy and procedure and manufacturer’s instructions

Surgical procedure tracer Cleaning—start of the day Cleaning—start of the day Horizontal surfaces Horizontal surfaces Damp dusted with a lint-free cloth and EPA-registered hospital detergent/disinfectant Damp dusted with a lint-free cloth and EPA-registered hospital detergent/disinfectant High touch surfaces cleaned and disinfected between patients High touch surfaces cleaned and disinfected between patients Anesthesia equipment is cleaned and disinfected between patients Anesthesia equipment is cleaned and disinfected between patients Reusable noncritical items (BP cuffs, etc.) are cleaned and disinfected between patients Reusable noncritical items (BP cuffs, etc.) are cleaned and disinfected between patients

Surgical procedure tracer Terminal cleaning of Operating Rooms Terminal cleaning of Operating Rooms After the last procedure of the day After the last procedure of the day Including weekends! Including weekends! Includes Includes Wet-vacuuming or moping the floor with an EPA-registered disinfectant Wet-vacuuming or moping the floor with an EPA-registered disinfectant All surfaces All surfaces Internal components of anesthesia machine breathing circuit are cleaned according to manufacturer’s instructions Internal components of anesthesia machine breathing circuit are cleaned according to manufacturer’s instructions

Surgical procedure tracer Ventilation requirements Ventilation requirements Positive pressure, 15 air exchanges per hour—at least 3 of which are fresh air Positive pressure, 15 air exchanges per hour—at least 3 of which are fresh air 90% filtration 90% filtration HEPA optional HEPA optional Air filters are checked regularly and replaced according to hospital policies and procedures Air filters are checked regularly and replaced according to hospital policies and procedures Temperature and relative humidity are maintained at required levels Temperature and relative humidity are maintained at required levels Doors are self-closing Doors are self-closing Air vents and grill work are clean and dry Air vents and grill work are clean and dry

A Protective Environment (e.g. Bone Marrow patients) Positive pressure—air flow out to the corridor from the room Positive pressure—air flow out to the corridor from the room 12 air exchanges per hour 12 air exchanges per hour Supply air is HEPA filtered Supply air is HEPA filtered Well sealed rooms so that there are no penetration spaces in the walls, ceilings or windows Well sealed rooms so that there are no penetration spaces in the walls, ceilings or windows Self closing door that fully closes on all room exits Self closing door that fully closes on all room exits Failures are addressed and documented Failures are addressed and documented Ventilation requirements are monitored using visual methods Ventilation requirements are monitored using visual methods “Kleenex test”; flutter strips, etc. “Kleenex test”; flutter strips, etc.

QUESTIONS? Please submit questions to: